Curriculum Vitae

Nama Lahir Alamat Istri Anak/Mantu/Cucu Pendidikan : : : : : : I Gede Arinton Singaraja, 1 Januari 1950 Jl. Pramuka 249 Purwokerto 1 5/3/3 1. dr. umum FK. UNUD 1977 2. dr. SpPD FK. UNDIP 1987 3. MKom STIBBi Jkt 1999 4. MMR UNSUD 2005 5. KGEH FK. UI 2007 6. Doktor Ilmu Kedokteran UNDIP 2008 : Bag. Penyakit. Dalam RSUD. Margono Soekarjo/FKIK Unsud Purwokerto Pelatihan Endoscopy di RSU dr. : 1. Hasan Sadikin Bandung. 2. International Endoscopy Workshop 2007, Jakarta 5 7 April 2007. 3. Training Endoscopy Showa University Yokohama 2009

Pekerjaan Pendidikan Tambahan

Varices in Liver Cirrhosis

Dr.dr. I Gede Arinton,SpPD-KGEH The Internal Medicine of FKIK Unoed Purwokerto 2012

Introduction
Prevalence CH - increased from 9%

(1996)-18.5% (2006)
Longitudinal studies VE &/or

gastric varices - eventually- in all

cirrhotic patients Once developed- tend :
to increase in size to bleed.

Introduction
Baveno IV - Status classification of cirrhosis : Stage 1: no varices, no ascites

Stage 2: varices, no ascites;

Stage 3: ascitesvarices Stage 4: bleedingascites.

Introduction
Mortality : 20%
Risk of rebleeding if no Th/ 60%

--- strategies Dx, prophylaxis I (first

bleed) & II(rebleeding). --- to identify the patients at risk of bleeding

The mechanisms variceal formation & rupture

The mechanisms variceal formation & rupture

Abraldes & Bosch,2005

Martell et al, 2010

The natural history

DEVELOPMENT OF VE :
HVPG >10 mmHg- strong

predictor
No other factors

The natural history

PROGRESSIONSMALL-LARGE
Once developed- small to large(5-30%/yr) Factors :
ChildPugh score E/ alcoholic Red wale markings HVPG

The natural history

FIRST BLEEDING
25%/2 yr Predictive factors :
Variceal size-HVPG The ChildPugh classification Red wale marks

Prophylaxis
Primary Secondary

Prophylaxis
Venodilators nitrates Shunting
Splanchnic vasocon. : vasopressin & ana. somatostatin & ana NSBB

STE EVL

Pre-Primary
1. Pre-primary prophylaxis
(prevention of the formation of

varices)- Baveno V :
An important area of research Predictive HVPG>10 mm Hg

Primary
1. Pre-primary prophylaxis
Experimental studies NSBB reduce portal pressure but insufficient evidence

Groszmann et al,2005

Primary
2. Primary prophylaxis :
All cirrhotic patients should be screened for varices at diagnosis :
Endos.- gold standard Non invasive

Endoscopic Dx
The risk of bleeding is related to:
the size of varices the presence of red signs Child-Pugh score

the size of
varices

Small <25% lumen

(the Italian
Liver
Medium 25-50% lumen

Cirrhosis
Project)
Large >50% lumen

red wale
markings

Baveno IV :
All CH endos. - screened

VE.
23 yrs intervals VE. <-> 12 yrs small varices

However-endoscopy :
High costs

Invasive - low compliance

noninvasive alternatives

Clinical Laboratory USG

poor validation - none

recommended in
everyday clinical practice

Biochemical & US parameters

31.Giannini et al,2003 32. Giannini et al,2006. 33. Thabut et al, 2006 44. Burton et al, 2007. 45.Berzigotti et al, 2008

Transient elastography

34. Kazemi et al,2006 46.Vizzutti et al, 2007.

CT scanning

35. Kim et al, 2007. 40.Kim et al, 2007. 47. Perri et al, 2008.

Video capsule endoscopy

36. Eisen et al, 2006. 37.Lapalus et al, 2006. 38.Groce et al, 2007. 39.de Franchis et al, 2008. 48.Pena et al, 2008.

 Primary prophylaxis 1. Prevention of the Growth of

Small Varices to Large Ones

2. Prevention of First Bleeding-

risk :
Red mark or

CP - C score

CONCLUSION: This trial suggests that propranolol administration cannot be recommended for the prevention of the development of large oesophageal varices in patients with cirrhosis; thus other studies are needed in selected subgroups of patients. Baveno V -- NSBB

Prevention of First Bleeding

Baveno V
Either NSBB or endoscopic band ligation (EBL) Carvedilol alternative NSBB+ISMN+spironolactone

Conclusion:
1.EVL >superior BB

2.Mortality - differerence <->

Primary Prophylaxis

Conclusions Patients with contraindications, intolerance or not responding to beta-blockers treated with band ligation achieve protection from variceal bleeding comparable to that of good responders to betablockers.

Secondary Prophylaxis
If untreated- risks of :
Rebleeding 63%
Death 33%

- recommendation -

Secondary Prophylaxis
Baveno V :

Time to start - as soon as possible from

day 6 of the index variceal episode BB+EVL > Th/ alone EVL unable/unwiling - BB+ISMN Fail endos.+ pharmaco. Th/ :
Transjugular Intra-hepatic Porto-systemic Shunt
(TIPS).

Transplantation

Algorithm

de Franchis,2010

Summary
VE bleeding - C/ PH

E/death 1/3 cirrhotic pts.

Patients with a high risk of bleeding need to be identified- prophylaksis.

Summary
The most important predictors:
Variceal size
The presence of red wale

markings
The severity of liver

dysfunction(ChildPugh score)

Summary
Endoscopic variceal ligation--

alternative to NSBB
Pharma. & endos. Th/ - fail-TIPS or transplantation

Thank You